Common Pediatric Lower Limb Disorders

1. Common Pediatric Lower Limb Disorders Dr.Kholoud Al-Zain Assistant Professor Consultant, Pediatric Orthopedic Surgeon Dec- 2016 Acknowledgement: Dr.Abdalmonem Alsiddiky Dr.Khalid Bakarman Prof. M. Zamzam

2. Topics to Cover • In-toeing • Genu (varus & valgus), & proximal tibia vara • Club foot • L.L deformities in C.P patients • Limping & leg length inequality • Leg aches

3. 1) Intoeing

4. Intoeing- Evaluation • Detailed history • Onset, who noticed it, progression • Fall a lot • How sits on the ground • Screening examination (head to toe) • Pathology at the level of: • Femoral anteversion • Tibial torsion • Forefoot adduction • Wandering big toe

5. Intoeing- Asses rotational profile Pathology Level Special Test Hips rotational profile: Supine Prone Inter-malleolus axis: Supine Prone Foot thigh axis Heel bisector line • Femoral anteversion • Tibial torsion • Forefoot adduction • Wandering big toe

6. Intoeing- Special Test Foot Propagation Angle  normal is (-10°) to (+15°)

7. Intoeing- Femoral Anteversion Hips rotational profile, supine  IR/ER normal = 40-45/45-50°

8. Intoeing- Femoral Anteversion Hips rotational profile  prone

9. Intoeing- Tibial Torsion Inter-malleolus axis Supine position Sitting position

10. Intoeing- Tibial Torsion Foot Thigh Axis  normal (0°) to (-10°)

11. Intoeing- Tibial Torsion Foot Thigh Axis  normal (0°) to (-10°)

12. Intoeing- Forefoot Adduction Heel bisector line  normal along 2 toe

13. Intoeing- Adducted Big Toe

14. Intoeing- Treatment • Establish correct diagnosis • Parents education • Annual clinic F/U  asses degree of deformity • Femoral anti-version  sit cross legged • Tibial torsion  spontaneous improvement • Forefoot adduction  anti-version shoes, or proper shoes reversal • Adducted big toe  spontaneous improvement

15. Intoeing- Treatment • Operative correctionindicated for children: • (> 8) years of age • With significant cosmetic and functional deformity  <1%

16. 2) Genu Varus & Valgus

17. Genu Varum and Genu Valgum • Definition: Bow legs Knock knees

18. Normal Genu Varum and Genu Valgum

19. Genu Varum and Genu Valgum • Types: • Physiological is usually  bilateral • Pathological  can be unilateral

20. Genu Varum and Genu Valgum • Types: • Physiologic • Pathologic

21. Genu Varum and Genu Valgum • Evaluation • History (detailed) • Examination (signs of Rickets) • Laboratory

22. Genu Varum and Genu Valgum

23. Genu Varum and Genu Valgum

24. Genu Varum and Genu Valgum • Evaluation: • Imaging Rickets

25. Genu Varum and Genu Valgum • Management principles: • Non-operative: • Physiological  usually • Pathological  must treat underlying cause, as rickets • Epiphysiodesis • Corrective osteotomies

26. “Proximal Tibia Vara”

27. Proximal Tibia Vara • “Blount disease”: damage of proximal medial tibial growth plate of unknown cause • Usually: • Overweight • Dark skinned • Types: • Infantile  < 3y of age, & usually early walkers • Juvenile  3 -10 y, combination • Adolescent  > 10y, & usually unilateral

28. Blount Disease Unilateral Bilateral • Types: • Infantile  usually in over weight & early walkers • Adolescent  usually over weight & unilateral

29. Blount Disease • Staging:

30. Blount Disease

31. Blount Disease • MRI is mandatory: • When: • Sever cases • Recurrence • Why?

32. 3) Club Foot

33. Clubfoot • Etiology • Postural  fully correctable • Idiopathic (CTEV)  partially correctable • Secondary (Spina Bifida)  rigid deformity, pt needs workup

34. Clubfoot • Clinical examination Characteristic Deformity : • Hind foot: • Equinus (Ankle joint) • Varus (Subtalar joint) • Mid & fore foot: • Forefoot Adduction • Cavus

35. Clubfoot

36. Clubfoot • Clinical examination: • Deformities don’t prevent walking • Calf muscles wasting • Internal torsion of the leg • Foot is smaller in unilateral affection • Callosities at abnormal pressure areas • Short Achilles tendon • Heel is high and small • No creases behind Heel • Abnormal crease in middle of the foot

37. Clubfoot • Management: The goal of treatment for is to obtain a foot that is plantigrade, functional, painless, and stable over time A cosmetically pleasing appearance is also an important goal sought by surgeon and family

38. Clubfoot • Manipulation and serial casts: • Validity up to 12 months  soft tissue becomes more tight • Technique “Ponseti”  3 stages, weekly basis (usually by 6-8w)

39. Clubfoot • Manipulation and serial casts: • Maintaining correction “Dennis Brown Splint”  3-4y old

40. Clubfoot • Manipulation and serial casts: • Follow up  watch and avoid recurrence, till 9y old • Avoid false correction  by going in sequence • When to stop ?  not improving, pressure ulcers

41. Clubfoot • Indications of surgical treatment: • Late presentation(>12 months of age) • Complementary to conservative treatment (residual forefoot adduction) • Failure of conservative treatment • Recurrence after conservative treatment

42. Clubfoot • Types of surgery: • Soft tissue

43. Clubfoot • Types of surgery: • Bony

44. Clubfoot • Types of surgery: • If sever, rigid, and in an older child

45. Clubfoot • Types of surgery: • If sever, rigid, and in an older child (salvage)

46. 4) L.L Deformities inC.P Patients

47. Lower Limb Deformities in CP Child • C.P is  a non-progressive brain insult that occurred during the peri-natal period. • Causes  skeletal muscles imbalance that affects joint’s movements. • Can be associated with: • Mental retardation (various degrees) • Hydrocephalus and V.P shunt • Convulsions • Its not-un-common

48. Lower Limb Deformities in CP Child • Physiological classification: • Spastic • Athetosis • Ataxia • Rigidity • Mixed • Topographic classification: • Monoplegia • Diplegia • Paraplegia • Hemiplegia • Bilateral hemiplegia • Triplegia • Quadriplegia or tetraplegia

49. Lower Limb Deformities in CP Child • Hip • Flexion • Adduction • Internal rotation • Knee • Flexion • Ankle • Equinus • Varus or valgus • Gait • Intoeing • Scissoring

50. Lower Limb Deformities in CP Child • Assessment: • Gait